FIDELITY GUARANTEE INSURANCE PROPOSAL

FIDELITY GUARANTEE INSURANCE PROPOSAL
Full Name of Proposer
Address
Occupation / Business
Telephone No.
Date of Birth

MonthDayYear
Date
Have you satisfied yourself by enquiry that all the employees to be covered are of trustworthy character and of right habits
Have you always been satisfied with the honesty and general conduct of the employees?
have their accounts always been in proper data
Are they so now
Are any of the employees in your debt?
If so to what extent
Have you sustained any losses through the declaration of any employee?
If so, please state to what extent and indicate the method of declaration and steps taken to prevent a recurrence
Has any employee previously been in your employment without security having been obtained'
If so, why is this insurance now required?
Will any other security be taken for any employee?
Will your accounts be professionally audited and if so, at what intervals
Who are your present auditors
Are you at present insured or have you ever proposed insurance in respect of fidelity risks?
Name of Company
If so, has any such proposal or renewal ever been

declinedwithdrawncharged an increased rate or subjected to special restrictions?
Please supply as fully and clearly as possible the following information in regard to the system of supervision and the employees duties and responsibilities.
In what way will monies pass through the hands of employees, i.e. by collection, sales or how otherwise?
Will employees be required to give printed receipts from a book with counterfoils?
If so, how often will the counterfoils be examined and checked?
Please state your method of payment of the following (i.e. by cheque, cash, retention from collections from customers, or how otherwise)
salaries
commission
travelling expenses
Are any employees to be a responsible for bad debts
If so, to what extent?
a What is the usual credit a given by you?
In what manner do you treat overdue accounts?
How often will you send by post statements of outstanding accounts to all customers with amounts against them in your book?
Will this be done solely b by employees not with direct collection of cash from customers?
will any of the employees have control of securities, goods or stock?
If so please state
The nature and value thereof
At what intervals they c will be examined and checked independently of controlling employee
Whether this examination d will be made without controlling employees foreknowledge
The data when last examined and found correct
Will all bank accounts be in the name of the employer
What signatures will be necessary to operate on the bank accounts
Where it is necessary to allow an employee to draw cheques for disbursement on his own signature will a separate bank account be kept which may be replenished from time to time by the employer
Will any employee have power to overdraw any bank account or to pledge the employer's in any way?
How often will you examine a the bank pass book and check the entries against the cask book independently of controlling employee
Will this examination be made Without controlling employee's Foreknowledge
what supervision will be exercised over petty cash transaction?
How often and by whom will all subsidiary cash books be checked
If cash payments are made to any employee for wages and/or commission please state if each total withdrawal for such cash payments is checked against the total of such payments
If so by whom?
Are any employees allowed to make ledger postings?
If so, what method do you employ to ensure that no cash receipts are posted to the ledger unless first posted to the cash book?
What is the precise procedure for the payment of wages
How often will you require employees to send in statements of cash received and to remit money
What will be the maximum duration of any journey
Are any employees allowed to represent other firms
Please complete the table below
DECLARATION

It is the duty of the proposer to disclose all material facts relevant to the risk. A material fact is one that is likely to influence our judgment and acceptance of your proposal. If your proposal is a renewal, it should include any change in facts previously advised to us. If you are in any doubt about facts considered material, disclose them. Please note that failure to disclose a material fact or if any information provided proves to be incorrect, we may void your policy and decline to pay any claim.

I/We declare that the statements and particulars made by me/us in this proposal are, to the best of my/our belief, complete and true and I/we agree that this proposal, together with any other information supplied by me/us, shall form the basis of the contract of insurance effected thereon.

I further declare and agree that if the statement and particulars above have been completed in the handwriting of any other person other than the undersigned, such person is deemed to be the representative of the proposer for the purpose of completing this proposal.

Signing this proposal form does not bind the proposer or underwriter to complete this insurance.
Date

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Date
Signature

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FIDELITY GUARANTEE INSURANCE PROPOSAL

Are you at present insured or have you ever proposed insurance in respect of fidelity risks?

Please supply as fully and clearly as possible the following information in regard to the system of supervision and the employees duties and responsibilities.

Please state your method of payment of the following (i.e. by cheque, cash, retention from collections from customers, or how otherwise)

Will any employee have power to overdraw any bank account or to pledge the employer's in any way?